CPT® codes 64418 and 19380 were reported together for the injection of the supra capsular nerve with anesthetic agent (64418) with revision of a reconstructed breast (19380). The injection was denied as a bundled service. Colum1/Column2 Edits Column 1 Column 2 Effective Date Deletion Date Modifier PTP Edit Rationale 19380 64418 20090401 * 0 Standards of medical / surgical practice What is the next step for the biller? A.Resubmit corrected claim adding modifier -59 to 64418. B.Resubmit corrected claim adding modifier -51 to 64418. C.Move the charge for the bundled procedure to patient responsibility D.Write-off the charge for 64418 because it is a bundled procedure

Medicaid covers EPSDT services. What is the definition of this acronym?   A.Early Postoperative Screening, Diagnostic, and Treatment B.Early Pregnancy Screening, Diagnostic, and Treatment C.Established Patient Screening, Diagnostic, and Treatment D.Early and Periodic Screening, Diagnostic, and Treatment

When submitting a Medigap policy, which option is an example of how the patient’s ID number should appear in item 9a of the CMS-1500 claim form?   A.123456789 B.123456789A C.MGAP 123456789 D.AETNA 123456789 MEDIGAP

Do annual CPT® code changes affect a physician’s office superbill?   A.No, because the physician performs the same procedures year after year. B.Yes, it is necessary to update the superbill with current CPT® codes but deleted CPT® codes should remain on the superbill for cross-referencing. C.Yes, the superbill needs to be updated with current CPT® codes and the deleted CPT® codes removed. D.No, because new codes can be accessed in the CPT® code book if needed.

Which of the following information is NOT required when requesting a prior authorization? A.The ordering physician B.The amount of time needed to complete the procedure C.Anticipated dates of surgery D.ICD-10-CM code(s)

Case 3 Surgical Specialists-Outpatient Surgery Preauthorization Form Date: 08/01/20XX Surgeon: Brian Surgery, MD Assistant Surgeon: John Smith, MD Surgeon NPI: 8908900989 Member Name: Doe Jane A Last First Middle Date of Birth: 06/07/1971            Insurance Carrier: Medical Insurance Specialists Policy Number: 589908765 Group Number: 97809 Date of Surgery: 8/15/20XX Facility Name: General Outpatient Hospital Surgical Center Facility NPI: 4567891923 Facility Address: 1234 Main Street, Here, TX Diagnosis: Old disruption of posterior cruciate ligament Diagnosis code: M23.50 Procedure: Arthroscopic posterior cruciate ligament repair Procedure code: 29889 Fee for Procedure: $2500.00 Contracted Fee: $2000.00 Type of Care (select one): ____ Inpatient ____ 23 Hour Observation X Outpatient Type of Anesthesia (select one): X General ____ Local Preauthorization Number: 2348995786 Insurance Paid Percentage: 70% of the allowable rate after $1500 deductible is met. Patient Responsibility: Patient has $700 deductible remaining that must be met. After deductible is met, patient pays 30% of the allowable rate.   49.Based on the information obtained during the preauthorization, how much is patient responsibility if the claim is paid?   A.$910.00 B.$1500.00 C.$1650.00 D.$1090.00

To compare units of service with CPT® and HCPCS level II codes, CMS added which of the following to the NCCI program?   A.Medically utilized edits B.Medically undetermined edits C.Medically unlikely edits D.Medically unusual edits

What is a co-payment?   A.An amount paid every month by the policyholder to maintain health insurance coverage. B.A percentage of the allowed amount that the patient is responsible for. C.A flat amount paid to the healthcare provider when the policyholder is seen for an office visit. D.The adjusted amount based on the insurance policy requirements.

A claim has been processed by the payer, payment received, and posted to the patient’s account. What is the next step in the billing process?   A.No further steps need to be taken. B.A receipt of payment is sent to the payer. C.Patient is notified at 60 days of any remaining patient responsibility. D.A statement is sent notifying the patient of their remaining responsibility.

Which of the following statements is true regarding Medicaid?   A.Medicaid eligibility policies are the same for states of similar size and geographic region. B.Medicaid eligibility is clear and consistent from state to state. C.Medicaid programs receive matching federal funding only if certain healthcare services are provided to eligible individuals. D.Medicaid programs must provide medical assistance for all poor persons.